Implementing COVID-19 home-based care (HBC) using community health volunteers: Early experiences and lessons learned in Uganda, January - May 2021

Ben Masiira^1,&, Atek Kagirita², Herbert Kazoora¹, Bernard Lubwama², Emmanuel Kaggwa³, Faith Nakiyimba³, Issa Makumbi², Winyi Kaboyo⁴, Daniel Albert Cohn⁵, Simon Nyovuura Antara¹, Henry Mwebesa²

 

¹African Field Epidemiology Network, Programs Department, Kampala, Uganda, ²Ministry of Health, Kampala, Uganda, ³Masaka District Local Government, Department of Health, Masaka, Uganda, ⁴DAI, Tackling Deadly Diseases in Africa (TDDA) programme, Kampala, Uganda, ⁵DAI, Tackling Deadly Diseases in Africa (TDDA) programme, Apsley, Hertfordshire, United Kingdom

 

 

^&Corresponding author
Ben Masiira, African Field Epidemiology Network, P.O Box 12874, Kampala, Uganda.

 

 

 

 

The emergence of coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was first detected in Wuhan City, China in December 2019. By May 2021, it had caused 169.5 million cases and 3.5 million deaths of which 3.4 million cases and 87,000 deaths were reported from Africa [1-4]. In the World Health Organization´s African region, 19 countries (40%), including Uganda, were experiencing a significant increase in the number of COVID-19 new infections by the end of May 2021 [3].

 

Uganda recorded the first case of COVID-19 on 21 March 2020 [5]. The initial interventions from Uganda´s government, which included a country-wide lockdown, played a substantial role in containing the spread of the epidemic but community transmission increased rapidly once the control measures were eased in June 2020. By 30 September 2020, Uganda was in Phase 4 of the epidemic characterized by widespread community spread with an average of 1,300 cases per week [6]. Between February and April 2021, the number of reported new COVID-19 infections declined, fluctuating between 10 and 60 cases per day [7-14], after which the country went into a second wave of COVID-19 [15-17]. As of 30 May 2021, the cumulative COVID-19 case count was 47,763 including 362 deaths (case fatality rate of 0.8%) [17].

 

As COVID-19 overstretched national health care systems globally, innovative strategies and tools that could contain the pandemic became increasingly necessary. One such strategy was home-based care (HBC) for management of mild and moderate cases of COVID-19 as proposed by WHO [18, 19]. Management of asymptomatic patients and those with mild to moderate symptoms at home has the advantage of offsetting the pressure on health facilities and maximizing the use of limited clinical resources; it can also substantially reduce the risk of infection to health workers and other individuals in health facilities [20, 21] as occurred in Italy where within 35 days of response to the COVID-19 epidemic, 8,920 health workers were infected with COVID-19, hampering hospitals´ capacity to respond and also causing early spread of infection to patients who were under management for other medical conditions [21]. In-person home visits and virtual monitoring by health workers are among the strategies that have been used to implement the HBC approach for COVID-19 patients with mild to moderate symptoms [22-24].

 

The initial COVID-19 response strategy in Uganda was institutional isolation and management of all confirmed COVID-19 cases using hospitals and other designated sites, and in-person visits by health workers for all the listed contacts of confirmed cases. However, by the end of September 2020, the COVID-19 epidemic in Uganda had expanded to such a magnitude that health facilities were overwhelmed and unable to admit all positive cases. To address this challenge, the Ministry of Health (MoH) adopted the HBC strategy to manage COVID-19 patients with mild to moderate symptoms [6, 25].

 

However, the country´s districts were not yet familiar with the HBC approach and lacked the financial and human resources and other logistics to implement the strategy. The objective was to assist one district that was at high risk for COVID-19 in rolling out the HBC intervention and in so doing to document experiences and lessons learned to inform the rollout of HBC in other districts in the country. The intervention was implemented from January-May 2021.

 

 

Implementation site

 

The intervention was implemented in Masaka District which is located in southwestern Uganda Figure 1, about 125 Km from Kampala City, the capital of Uganda. The district has an estimated population of 342,300 with 53% below 18 years of age [26, 27]. The major economic activity is agriculture with the main cash crops including maize, beans, coffee, sweet potatoes, and bananas, as well as livestock [26]. Masaka District was selected because it ranked among the top 6 districts with a high burden of COVID-19 (with a daily case count between 3 and 29) during the planning phase for the HBC intervention [28-32] and presence of active community health workers who are known as village health teams (VHTs). In addition, the district had an increased risk of cross-border COVID-19 transmission because many of its towns are major resting spots for high volumes of cross-border cargo trucks and population movements.

 

Identification of the key stakeholders

 

The district-level implementation team identified the key stakeholders for COVID-19 HBC at district, sub-county, parish, and village levels. These stakeholders included politicians, religious and opinion leaders, health workers, heads of schools/tertiary training institutions, implementing partners, and VHTs.

 

Activation of COVID-19 coordination structures

 

The MoH team first reactivated the COVID-19 district task force (DTF) weekly meetings which had not been held for the preceding two months. The main responsibilities of the DTF, which was made up of the district´s political and technical leadership, were to design strategies, supervise response interventions, lead community mobilization and sensitization, and mobilize resources. The reactivated DTF held weekly meetings to discuss the COVID-19 epidemic and HBC, and reported to the national task force (NTF) on epidemics and public health emergencies. The district technical team with support from the MoH team then activated sub-district level COVID-19 task forces in each of the 9 sub-counties and 36 parishes. The sub-district level task forces were responsible for mobilization and sensitization of communities on COVID-19 prevention and control, and supervision of HBC activities. The DTF coordinated with other public health programs such as Expanded Program for Immunization (EPI), Human Immunodeficiency Virus (HIV), Tuberculosis and Maternity Services, by inviting their respective focal persons to make presentations providing updates on their work.

 

Orientation of stakeholders on the HBC strategy

 

During the orientations, the importance of collaboration and transparency among stakeholders was emphasized. The following stakeholders were oriented:

 

• District task force and district health team: The MoH team oriented the 20-member DTF on coordination and their roles and responsibilities. Afterwards, the MoH team conducted a training-of-trainers training for 10 members of the district technical team, known as the district health team (DHT). This orientation covered the DHT´s roles and responsibilities, HBC guidelines and coordination, and screening and management of confirmed COVID-19 cases within a household setting. The DHT then cascaded the HBC orientation to lower-level health workers, sub-county and parish task forces, community/opinion leaders, and VHTs.

 

• Health care workers: A total of 93 health workers were oriented, consisting of health sub-district managers, in-charges of health facilities, and frontline health workers involved in COVID-19 care and surveillance. The orientation covered the epidemiological situation of COVID-19 in the district, coordination, implementation strategy for HBC, criteria for HBC, case management, and the reporting framework and tools.

 

•Sub-county and parish task forces: Nine sub-county task forces each comprising five members, and 39 parish task forces each comprising four members, were oriented on COVID-19 infection transmission, prevention and control, and the HBC strategy.

 

•Village health teams: A total of 352 VHTs were oriented, one from each of the 352 villages constituting Masaka District. The orientation covered COVID-19 prevention and control, detecting symptoms of COVID-19, patient monitoring, and referral pathways. The VHTs were provided with thermometers, reporting forms, face masks, and hand sanitizer for conducting home visits.

 

•Community/opinion leaders: Thirty-four influential community/opinion leaders, including religious and cultural leaders, heads of schools/tertiary training institutions, journalists, and local politicians, were oriented on COVID-19 prevention, HBC strategy, and their roles in implementation of HBC in their respective communities.

 

Procurement of essential supplies

 

The MoH team procured and delivered face masks to the district to support implementation of HBC activities. Case-investigation and reporting forms were printed and distributed to streamline case investigation and reporting. Digital thermometers were procured and delivered to the VHTs, and patients with confirmed COVID-19 for daily monitoring. The district´s surveillance and laboratory teams were supported with fuel to investigate suspected cases, and to facilitate specimen transportation.

 

Procedure for COVID-19 HBC

 

Patients were diagnosed at health facilities by health workers. For each diagnosed case, the health facility surveillance team conducted a home visit and took samples from house-hold contacts for COVID-19 testing. Home care management was applied to COVID-19 patients who met the following criteria: (i) mild or no symptoms, (ii) without known risk of developing complications or progressing to severe disease, (iii) living in a home that was assessed and found to be suitable for home care, (iv) clear understanding of the rationale for staying home until cleared by health officials, and (v) discharged from a treatment center to continue with home-based management. Patients who did not meet all the above criteria were managed in COVID-19 treatment centers.

 

HBC-eligible patients were taken through a counseling session at health facilities focusing on prevention of infection during home isolation and on the warning signs associated with progression to severe disease. The VHTs conducted daily monitoring visits to document patients´ (self-measured) temperature and to document any emerging symptoms. The VHTs were not allowed to make physical contact or to examine the patient. If a COVID-19 patient or contact developed a high temperature or other dangerous symptoms, the VHT contacted a health facility/district surveillance focal person who came to conduct further assessment. The VHTs also monitored household contacts for possible symptoms of COVID-19 and made referrals when appropriate.

 

Supervision of the HBC intervention

 

Day-to-day supervision of the intervention was conducted by the DHT led by the district health officer (DHO). The MoH team conducted monthly supervisory visits to assess progress, provide technical support, review data quality, and ensure that the objectives of the intervention were being met. The supervision teams interacted with VHTs and patients and they noted and addressed any challenges faced by the VHTs and patients under home care.

 

Enhanced community and health facility surveillance

 

The VHTs, opinion leaders, and community leaders reported suspected COVID-19 cases to health facility surveillance focal persons or to the district surveillance focal person. The DHT enhanced COVID-19 surveillance at health facilities through distribution of case definitions and supervision of continuing medical education (CME) sessions. CME sessions were conducted at 26 of the 36 health facilities by the health workers who had received orientation on HBC; in the other 10 facilities the sessions did not take place due to competing activities.

 

Upon detection of an alert, the health worker, VHT member, or community member sent a notification to the health facility or district surveillance focal person for verification and further investigation if it fitted within the case definition. Financial support was provided to transport COVID-19 or other priority disease specimens to a collection point/hub from which the specimens were transported to the national reference laboratory.

 

Alert reporting improved from an average of 60 alerts per month in October-December 2020 to over 300 alerts per month from January to May 2021. In total 2,050 alerts were reported, of which 1,386 (68%) were investigated for COVID-19. Out of the 1,386 alerts investigated, 120 (9%) tested positive, of which 64 (53%) were females.

 

Enhanced community engagement and sensitization

 

Community sensitization was conducted using radio jingles and radio talk shows in the local language, film vans, and sensitization meetings. Targeted health education sessions were conducted in high-risk locations including hotels, markets, and fishing communities, villages where a case of COVID-19 had been confirmed, and in schools and tertiary institutions each with more than 500 learners. The heads of the educational institutions ensured that teachers delivered sensitization sessions on COVID-19 to students every week and enforced mask wearing and hand washing. Politicians and community leaders talked about COVID-19 prevention during their interaction with communities.

 

COVID-19 cases detected during HBC implementation

 

A total of 120 COVID-19 cases were diagnosed from 16 villages during implementation of the HBC intervention of which 108 (90%) were managed by a total of 28 VHTs using the HBC approach. The number of confirmed COVID-19 cases increased from 2 cases in January 2021 to 64 cases in May 2021. Twelve cases (10%) were referred to the treatment center for management of which eight had severe symptoms, two were above 60 years of age, and one had diabetes and hypertension and died in the treatment centre. Two cases (2%) managed under the HBC approach developed severe symptoms and were referred to the treatment center for further management.

 

Experiences

 

The COVID-19 HBC intervention in Masaka District commenced four months after the MoH adopted the HBC strategy. Although the district had committed to implement the strategy, it was struggling to roll it out for all patients. Monitoring of the patients was conducted by the district surveillance focal person, the HBC focal person at Masaka regional referral hospital, and a few committed COVID-19 surveillance focal-persons at health facilities.

 

During early stages of the HBC intervention some health workers expressed skepticism about the HBC strategy. Their main concerns included: i) delayed detection by the VHTs of the symptoms associated with progression to severe COVID-19 infection, ii) increased risk of transmission of COVID-19 among home contacts, VHTs, and the community due to inconsistent adherence to guidelines for infection prevention, iii) challenges in accessing adequate supplies for infection prevention and control within households with confirmed cases, and iv) patient safety in the hands of VHTs who lacked knowledge and technical capacity to detect dangerous symptoms. These issues were important and helped to guide the implementation of the HBC intervention.

 

The mobilization and deployment of the VHTs to support the COVID-19 HBC intervention eased the pressure on Masaka District´s health personnel. Although the VHTs were already playing a pivotal role in the implementation of other public health programs, an anticipated challenge was that the VHTs would not cooperate for fear of being infected with COVID-19. However, once the VHTs were oriented, they felt empowered and confident to manage and provide the required support to COVID-19 cases. The VHTs were involved in patient monitoring and delivered health promotion and infection prevention messages within the affected households. There were no confirmed infections among the VHTs who were involved in implementation of the HBC intervention.

 

Despite health workers´ initial skepticism about the HBC strategy, patients and the community at large received the HBC intervention favourably. This favorable reception was in part linked to community resentment toward the original strategy of managing patients in treatment centers, based on reports of: i) poor feeding, ii) congestion in the treatment centers, iii) family members not being able to participate in the management or not being able to access their loved ones, and iv) rumors that patients admitted in treatment centers were being harmed or killed to stop transmission of the disease.

 

Patients reported feeling safe and satisfied with the care provided by the VHTs within their households:

 

“My VHT reviewed me on daily basis. He asked me about the symptoms I was experiencing, noted my temperature and provided me with reassurance that I was going to survive the infection” (Patient in Nyendo-Senyange village, translated from Luganda).

 

“After sending my two children to stay with relatives at my village home, I was taken care of by my wife in our house in Masaka. The VHT checked on me on daily basis to assess my condition and document any new symptoms I was experiencing. At the same time, I had access to the district surveillance focal person whom I would call at any time for consultation. Being managed at home was a good experience and at no time did I feel unsafe” (Patient in Kimanya village, translated from Luganda).

 

Challenges

 

Although the majority of patients had good experiences under home care, a few reported stigmatization by the community and in some cases, that stigmatization continued beyond discharge from home care. This was not surprising as several reports had indicated that individuals diagnosed with COVID-19 were exposed to high levels of stigmatization within communities in Uganda generally [33-35].

 

“During and after home-based care, my family and I were isolated by many people within our community. People stopped visiting our household and some would run away when one of my family members was seen approaching their home. Even the retail shop owners were not willing to serve me or any of my family members and as such we had to buy household supplies in distant locations where we were not known” (Patient in Kiyumba sub-county, translated from Luganda).

 

Lack of knowledge and misinformation have been identified as key drivers of stigma associated with infectious diseases including COVID-19 [36-38]. Therefore, it is important that communities are sensitized about stigma and provided with reliable information on COVID-19 prevention and transmission in the local language.

 

Patients with inadequate space in their homes had difficulty in self-isolating there. A similar finding was reported in Spain where patients managed under the HBC strategy found it difficult to isolate at home, potentially putting the community at risk of infection [39]. Patients with inadequate space were advised to self-isolate at a relative´s or friend´s home or to send some members of the family to their relatives/friends. Patients without an option for self-isolation were managed at COVID-19 treatment centers until they tested negative for COVID-19.

 

As the community became aware of the COVID-19 HBC option, the implementation team found it difficult to convince some HBC-ineligible patients to accept referral to the designated COVID-19 treatment centre as these patients preferred to be managed within the comfort of their homes. Although the HBC implementation team managed to counsel and convince these patients to accept admission, this created delays in referral and commencement of treatment.

 

Lessons learned

 

The key lessons learned during implementation of the HBC intervention included: i) a DTF platform can successfully be used to improve the coordination not only of the COVID-19 response but also of other public health programs such as EPI, HIV, and tuberculosis, ii) a district-level technical team that has been oriented by a more senior-level team, can in turn ably cascade an HBC intervention to the community level, iii) empowering VHTs with the required skills and knowledge is a critical part of the HBC intervention, and needs to be included as part of any successful attempt to replicate this pilot approach in other districts, iv) VHTs can implement the HBC strategy successfully, provided there are strong linkages to treatment centers to manage cases that progress to the severe stage, and v) rolling out HBC services is expected to lead to an increase in the number of COVID-19 confirmed cases due increased reporting and investigation of alerts.

 

 

This paper describes the process, experiences and lessons learned during one Ugandan district's transition from the approach of hospitalizing all confirmed COVID-19 cases, to an HBC strategy implemented using VHTs. The COVID-19 HBC approach was received and accepted favorably by the community, patients, and VHTs. To ensure the safety of patients and that of the VHTs themselves, it is important that VHTs are adequately empowered with the required knowledge and skills for monitoring of patients in a household setting. Additional resources such as infection prevention and control supplies (gloves and sanitizer) and thermometers should be provided to the VHTs to enable safe and effective patient monitoring. Stigmatization of COVID-19 patients within the community is a key challenge that can hinder implementation of the HBC strategy. Therefore, community-based approaches need to be designed to address stigmatization and to enable recovered patients to re-integrate in the community after they are discharged from home care.

 

 

The authors declare no competing interests.

 

 

Ben Masiira participated in project conception, design, implementation, and supervision of project activities and led manuscript writing. Atek Kagirita participated in project conception, design, provided technical oversight and coordination of the project at MoH and participated in manuscript writing at all stages. Herbert Kazoora participated in project conception, design, implementation, and supervision of project activities and he reviewed and participated in manuscript writing at various stages. Bernard Lubwama participated in project design, implementation, and supervision of project activities and he reviewed and participated in manuscript writing at various stages. Emmanuel Kaggwa participated in project coordination and supervision at district level and participated in manuscript writing. Faith Nakiyimba provided overall technical project oversight, project coordination and supervision at district level, and participated in manuscript writing and approval of the manuscript at district level. Issa Makumbi participated in the project design and coordination at MoH, and participated in the writing of the manuscript at all stages. Winyi Kaboyo participated in project conception and design, and participated in the writing of the manuscript at all stages. Daniel A. Cohn participated in the writing of the manuscript at all stages. Simon Antara participated in project conception and design, and participated in manuscript writing and provided AFENET's approval of the manuscript for publication. Henry Mwebesa provided overall project technical oversight at national level, participated in manuscript writing, and provided the Ministry of Health's final approval of the manuscript for publication.

 

 

We acknowledge the funding support offered by UK aid from the United Kingdom (UK) government, under the Tackling Deadly Diseases in Africa (TDDA) programme led by DAI. The views expressed are those of the authors and do not necessarily reflect the UK government's official policies, or the views, decisions, or policies of the institutions with which the authors are affiliated. Lastly, we thank the VHTs who participated in the monitoring of COVID-19 patients who were managed under the COVID-19 HBC strategy.

 

 

Figure 1: Location of the HBC intervention site (Masaka District)

 

 

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